Table 2 Characteristics of the interventions identified to support healthcare providers´ compliance with guideline recommendations for breast cancer

A. Computerized clinical decision support system

 Seroussi, Bouaud et al. [38,39,40,41,42,43, 64,65,66,67,68]

OncoDoc/OncoDoc2

In hospitals in France

Intervention not targeting a specific behavior. Rather, to support state-of-the-art clinical decision making, by increasing physician awareness and knowledge of CPGs contents.

Guideline-based computer decision support system, providing patient-specific recommendations in the management of non-metastatic invasive breast cancer according to local guidelines (CancerEst). The system relies on a formalized knowledge base structured as a decision tree.

Starting from the root of the decision tree, the physician user navigates through the knowledge base while answering questions and thus instantiating patient criteria. Guideline-based patient-centered therapeutic recommendations are provided when the navigation is completed, i.e., a leaf is reached

Computer system

Intervention available as part of routine clinical practice (healthcare professionals had unlimited access to it).

The intervention was used during multidisciplinary staff meetings, to inform therapeutic decisions concerning cancer patients.

 Eccher et al. 2014 [48]

OncoCure CDSS

Medical Oncology Unit, Hospital of Trento (Italy).

To support appropriate adjuvant medical treatment to BC patients during all the stages of therapy

Asbru-based decision support system implementing treatment protocols for breast cancer, which accesses data from an oncological electronic patient record.

Computer system

Two temporally distant groups of multidisciplinary panel discussions: 36 cases were discussed in meetings held in the last third of 2009, 25 cases were discussed in meetings held in the first third of 2012

B. Provider educational intervention

 Gorin et al. 2006 [50]

Not reported

Primary care centers in underserved community in New York (USA)

To increase mammography referrals in community-based urban physicians

Physician-directed education, academic detailing, using the American Cancer Society guidelines for the early detection of BC. Self-learning packets (i.e., professionally designed print materials, scientific articles, and a targeted verbal script)

Two Master’s level health educators

4 academic detailing visits over a 2-year period of time.

Academic detailing contacts were brief (average, 9.25 min). If the physician consented, the office-based breast cancer prevention materials were shared with the other staff as well. Visits were supplemented by 6 dinner seminars.

 Lane et al. 1991 [58]

Not reported

Primary care centers in New York (USA). Although the target were primary care centers, most of the intervention was delivered at the local community hospital.

To increase mammography referrals and physical breast examination for women 50 years of age and older.

Multimethod approach to physician education including conferences, physician newsletters, skills training, BC monograph, “question of the month” among hospital staff meetings, primary care office visits and patient education materials.

Research team

Intervention delivered over 2 years

 Ray-Coquard et al. 2002 [63]

Not reported

Hospitals in France (ONCORA cancer network)

Intervention not targeting a specific behavior, but rather to increase overall compliance by increasing physicians’ knowledge about the guidelines in place.

Monthly meetings where the relevant sections of the CPGs were presented. The information was then discussed, modified and/or validated by all the participating physicians from the hospitals to obtain a regional consensus. Two weeks after the meeting, the validated CPGs were sent to all the participating physicians who were expected to use them in their practice. No specific penalty or reward system was included in this implementation strategy.

Local opinion leaders (from the cancer center), who were both knowledgeable and credible for the specific cancer site.

Monthly meetings, taking place in 1995.

 Lane et al. 2001 [57]

Not reported

Primary care centres in NewYork (USA).

To increase mammography referrals

1–2 h in-office training program and/or self-study workbook according to physician CME need. The CME intervention was offered as a comprehensive, multifaceted package.

Master’s level nurse educator and standardized patient (trained to provide feedback to the physicians to enhance their clinical breast examination and communication skills).

1–2 h training session (tailored according to each physician's pre-intervention level of adherence to breast cancer screening guidelines and/or CME need)

 Kreizenbeck et al. 2020 [55]

Not reported

Regional community oncology clinics in Washington (USA)

Improve prescription in relation to the use of primary prophylactic colony stimulating factors for chemotherapy regimens with < 20% risk of febrile neutropenia

Academic detailing for oncologists at a regular meeting

Not reported

1 session

 McWhirter et al. 2007 [59]

Not reported

Cancer center in Toronto (Canada)

To reduce the number of unnecessary staging investigations performed

Multidisciplinary educational rounds, highlighting the Cancer Care Ontario Practice Guidelines, and reporting results of the audit of staging investigations. Attendance at the rounds included staff and trainees in medical and radiation oncology, surgical oncology and pathology. The guidelines were widely distributed to the medical, surgical and radiation oncologists, in a hard copy format.

Not reported

January–March 2003

 Calo et al. 2020 [44]

Strength after Breast Cancer (SABC)

Outpatient rehabilitation clinics in the USA

To improve knowledge about how to deliver evidence-based rehabilitative exercise interventions for breast cancer survivors

The online course was provided through a popular online platform for physical therapy continuing education (Klose Training and Consulting website; http://klosetraining.com/course/online/strength-abc). The covered all aspects of setting up and running the SABC program including how to obtain referrals from oncology clinicians, screen potential patients, coordinate with a certified lymphatic therapist, educate patients about lymphedema, teach the 4-session exercise program, instruct patients on how to log their progress, motivate patients to perform exercises, handle logistical considerations, and manage discharge and wrap-up. The course also provided all the materials needed to set up the program in clinics.

Online course prepared by the researchers

The online course was provided in 2015.

The course was 4-h long.

C. Audit and feedback interventions

 Veerbeek et al. 2011 [69]

Not reported

Hospitals in the Midwestern part of the Netherlands

To improve the diagnostic process and surgical treatment for women with breast cancer

Written report with regional benchmark information on nine performance indicators measuring quality of care based on BC National Guidelines. The intervention was based on the Plan-Do-Study-Act cycle for continuous quality improvement. Each year from 2002 until 2006, hospitals received a written report with regional benchmark information on each indicator. Furthermore, in 2004, 2005, and 2006, the care professionals attended training sessions twice a year. During these training sessions, an anonymous benchmark was presented in which the indicator scores for each hospital were compared with the regional mean score and the norm score. The care professionals generally discussed those indicator scores that clearly deviated from the regional mean score or the norm score with experts in the field. In 2006, 2007, and 2008, a member of the multidisciplinary team presented the benchmark information to the Oncology Committee within each hospital. This presentation for direct colleagues stimulated the care professionals to discuss the results more freely and to initiate improvement initiatives.

Research team

Intervention delivered from 2002 to 2006 (two sessions per year)

 Craft et al. 2000 [47]

Not reported

Breast cancer treatment facilities and medical practices in Australia

Increase awareness and knowledge about guideline treatment recommendations for breast cancer

Audit of healthcare provided to patients (based on medical records) according to four indicators. Data was fed back to each participating clinician, providing comparisons across the group and against the agreed criteria. Aggregated data across the whole clinician group were presented at regular meetings of the treatment group

Research team

May 1997 to July 1998

D. Multifaceted interventions

 Aspy et al. 2008 [37]

Not reported

Primary care practices in Oklahoma (USA)

To increase mammography referrals in women over 40

Multicomponent intervention, which included audit and feedback; academic detailing of exemplar principles and information from the medical literature; services of a practice facilitator; and information technology support. Practices were free to choose (or not) from the identified exemplar strategies or to modify them as necessary to fit the practice constraints of their individual settings.

Researchers developed the materials.

A trained practice facilitator spent at least 2 days per month at each practice and helped the practitioners design their interventions and facilitate the “Plan, Do, Study, Act” process.

Intervention delivered during 9 months

 Michielutte et al. 2005 [60]

Not reported

Primary care practices in North Carolina (USA)

To increase mammography referrals among women over 65

The intervention program was based on two theoretical models: Health Belief Model, and the Transtheoretical or Stages of Change model.

The intervention consisted on: provider education (information on issues in mammography for older women); written educational materials on BC and screening mailed to women; and a brief telephone counseling session for the women.

Researchers

The intervention lasted approximately 9 months. The intervention design was sequential, with progressively more intensive interventions introduced at each stage.

Hillman et al. 1998 [54]

Not reported

Primary care practices in Philadelphia (USA)

To increase screening mammography among women over 50

Semi-annual feedback to primary care providers regarding compliance with cancer screening guidelines and financial bonuses for "good" performers.

• Feedback reports documented a site’s scores on each screening measure and a total score across all measures, as well as planwide scores for comparison.

Bonuses ranged from $570 to $1260 per site, with an average of $775 per audit. Seventeen (of 26) sites received at least 1 bonus throughout the course of the study

Researchers

Intervention took place from 1993 to 1995.

Chart audits were performed at baseline and every 6 months for 1.5 years.

 Grady et al. 1997 [51]

Not reported

Small, primary care practices in Massachusetts (USA)

Increasing mammography referrals by primary care physicians

• Physician education: included discussion of charts illustrating historical breast cancer incidence the rising number of older women in the population, the strong association of breast cancer and age, and the relationship between physician encouragement and mammography use.

• Cue enhancement: two kinds of cues supplemented the educational material. General cues were posters provided for waiting or treatment rooms, chosen to emphasize breast cancer risk among older women and the efficacy of mammography. Specific cues were chart stickers in a schematic breast shape with spaces for recording three mammography referrals and completions.

• Feedback rewards: peer-comparison feedback about mammography use and token monetary rewards. Individualized feedback was provided in two charts that were mailed to each physician in the practices.

Researchers

1 year intervention (unclear dates).

Education: one session

Feedback: four feedback reports sent quarterly.

Financial incentive: check based on the percentage referred during each audit period (i.e., $50 for a 50% referral rate).

 Gilbo et al. 2018 [49]

Not reported

Hospitals in USA

Support the proper use selection of hypofractionation of breast irradiation (which was underutilized)

Five consensus-driven and evidence-based clinical directives to guide treatment decisions were implemented. Prospective contouring rounds were instituted, wherein the treating physicians presented their directive selection and patient contours for peer-review and consensus opinion.

Working committee that consisted of physicians, dosimetrists, nurses, and physics and therapy staff

Directives became available for its use as part of routine clinical practice in 2010

 Hill et al. 2018 [53]

Not reported

Health facilities part of the Gundersen Medical Foundation, including 30 regional clinics and 5 rural hospitals (USA)

To decrease laboratory testing for early breast cancer patients

• Provider education: PowerPoint presentations were delivered at 2-month intervals, where changes in breast cancer guidelines for testing were cited.

• Audit and feedback: peer performance comparisons (benchmarking) with full transparency to providers and tumor board attendees by disclosing individual ordering provider performance compared to others.

• Certification: specific questions that would qualify for continuing medical education credits.

• Patient education: Information fact sheets containing information on the guidelines were created for patient education at their initial appointment. In these, patients would be encouraged to discuss lab testing and imaging with their provider

• Financial incentives: To reward and incentivize providers, a plan was discussed to reward them for high guideline compliance with gift certificates to local restaurants.

• Health information technology: Implementation of alerts in the electronic medical records.

• Provider education: delivered by surgical resident-in-training, a medical student, and the principal investigator.

• Audit and feedback: by academic researcher

• Provider education: delivered at 2-month intervals beginning June 2016

• Audit and feedback: delivered in October 2016 and January 2017

 Ottevanger et al. 2004 [62]

Not reported

Hospitals part of the Comprehensive Cancer Centre (Netherlands)

• To support the provision of treatment according to a guideline for premenopausal node-positive breast cancer patients

• Audit and feedback: repeated feedback on the performance of the chemotherapy administration, timing and dosing was delivered through of oral presentations, during three breast cancer group meetings.

• Educational activities: Important literature that became available in that period on the dose intensity of chemotherapy, sequencing of radiotherapy and the importance of adequate axillary lymph node clearance were discussed

• Researchers

• Audit and feedback: Between 1993 and 1996.

• Educational activities: four consecutive meetings

 Coleman et al. 2003 [46]

Not reported

Primary care clinics in Arkansas (USAa)

To increase breast cancer screening among low-income, African American, and older women (increasing healthcare professionals’ knowledge to improve encouragement of screening)

• Use of standardized patients to observe and record providers’ performance followed by direct feedback: standardized patient was a lay woman trained in a particular clinical scenario to score and teach CBE using herself as a model.

• Newsletters to inform providers about screening methods: four newsletters in a format that was easy to read and clinically relevant for busy healthcare professionals in primary care. They provided the latest information about breast cancer screening, diagnosis, treatment, and rehabilitation.

• Posters and cards presenting key points about CBE and the importance of screening mammograms: Two sets of posters presenting key points about CBE and the importance of routine screening mammograms, along with laminated pocket-size cards with the same information, were provided to the clinics in the intervention group to display. The posters were designed to prompt women to discuss screening issues with providers

• Patient education materials about breast cancer screening available from the National Cancer Institute and American Cancer Society were mailed to clinics

Research team

May 1996–June 1998

 Armson et al. 2018 [36]

Not reported

Primary care practices in Canada

Increasing mammography referrals by primary care physicians

Set of iTools for patients and clinicians:

• Screening Recommendations for breast cancer with mammography (printed educational material targeted to clinicians)

• Screening recommendations for clinical breast exams and breast self-exams (printed educational material targeted to clinicians)

• Breast cancer online video: targeted to clinicians, exploring strategies for patient discussion around breast cancer screening issues

• Patient handout: “breast cancer screening—what is the right choice for me?” patient decision aid

• Patient handout: printed educational material with algorithm guides individuals re mammography

• Patient handout: Patient handout describing benefits and the risks of breast cancer for women between 40 and 49, 50–69, and 70–74 years of age. It includes a pictorial representation of outcome of screening in each age group including false positives, biopsy, and mastectomy

• Patient handout: printed educational material highlighting that CTFPHC recommends that women aged 50–74 schedule a mammogram every 2–3 years

Researchers/ Canadian Task Force on Preventive Health

September 2013 to august 2013

E. Other types of interventions

 Chambers et al. 1989 [45]

Not reported

Primary care practices in the USA

Increasing mammography referrals by primary care physicians

Provider reminders

Microcomputer tickler system for ordering of mammograms. The date of the last mammogram ordered and entered into the database was displayed in the comments section of the encounter form for each visit. This information was printed as “last mammogram: date”, or, if no mammogram was on record in the encounter form database, the notation was listed as “last mammogram: ?” Entering a physician-ordered mammogram into the database automatically updated the reminder in the comments section for subsequent visits.

Computer system

November 1986 (system available during 6 months)

 Wheeler et al. 2013 [70]

Community Care of North Carolina (CCNC) Program

Primary care practices in the USA

To support the provision of guideline-concordant follow-up care among breast cancer survivors.

Medical home program

Innovative medical home program to enhance primary care case management in vulnerable populations insured by Medicaid. Medicaid patients whose providers are members of one of the CCNC networks throughout the state are enrolled into a CCNC medical home, and their providers and the network receive per member per month payments for care coordination.

Health system

This medical home program became available in 1990 as part of routine care organization for eligible centres.

 Kubal et al. 2015 [56]

Not reported

Moffitt Cancer Center (USA)

To overcome the challenges of adherence to clinical pathways

Computerized vignettes

Computerized vignettes that simulate patient scenarios and ask clinicians to make decisions. The vignettes consisted of 12 different cases that required the provider to evaluate a simulated female patient for breast cancer or suspected breast cancer.

Researchers

March 2013 onwards. Providers completed 2 vignettes every 4 months for 6 rounds over a period of 20 months. Each vignette takes approximately 25 min to complete

 Munce et al. 2013 [61]

Not reported

Not implemented

Facilitate the uptake of the breast cancer screening guidelines

Integrated knowledge translation intervention

Integrated knowledge translation strategy based on the Knowledge to Action framework: seven action cycle phases to guide the development of a strategy to implement this knowledge (guidelines) in healthcare settings.

The suggested strategy resulting from the use of the framework targeted providers and patients, and included:

• Continuous medical education event targeted to physicians managers

• Point-of-care tools such as CDS tools, computer order-entry systems

• (reflecting new guidelines)

• Decision aids targeted to patients (through internet, patient decision groups, magazines)

Intervention developed by an interprofessional group of students as well as two faculty members met six times over three days at the KT Canada Summer Institute in 2011

Not applicable (intervention designed but not implemented)

 Groot et al. 2009 [52]

Not reported

Dutch Comprehensive Cancer Centre (Netherlands)

To improve overall compliance with breast cancer clinical guidelines

Medical critiquing system

Automated system to compare clinical actions performed by a physician with a predefined set of actions. The results were fed back to clinicians.

Computer system

January 2003—June 2004